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HRT and cardiovascular prevention

10 October 2012

A Danish study reported this week in the British Medical Journal has concluded that after 10 years of follow-up, women receiving HRT early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, with no apparent increase in risk of cancer, stroke, or blood clot.

1006 healthy women aged 45 to 58 who were recently menopausal were randomly allocated to receive HRT or placebo. Intervention was stopped after 11 years, but follow-up continued for up to 16 years.

The beneficial effects of taking HRT in this randomized trial, agree with data from observational studies which have consistently indicated a reduced risk of heart disease with the use of HRT. Confusion has arisen over the last decade following publication of results of HERS and WHI trials, which both suggested an increased risk of heart disease with the use of HRT. However, most women in these trials were older than 60 years and more than 10 years postmenopausal when starting HRT as part of the trials. Re-analyses of these and other randomized trials have now shown that heart disease and total mortality are reduced when HRT is initiated in women aged less than 60 years, or within 10 years of the menopause. This new Danish trial reinforces the message of a “window of opportunity” for cardiovascular benefit with HRT, while reassuringly emphasizes the safety of HRT in terms of no significant risks even when used for more than 10 years.

Commenting on behalf of Women’s Health Concern and the British Menopause Society, Dr John Stevenson:

“Its main importance is the absolute safety of HRT with long term use. Because of the young age of the women, the numbers of events are very small, ……but the trends are clear - a reduction in Coronary Heart Disease and in all-cause death, a significant reduction when these endpoints are combined (which was the planned primary endpoint of the study), no increase in stroke, VTE or any cancer, and a non-significant reduction in breast cancer (i.e. no increase). The strength of this study is the long duration of use. The safety concerns generated 10 years ago by biased reporting and mis-interpretation of HRT studies have been steadily assuaged by further analyses and reappraisals of those studies. This latest study totally reinforces this. The mantra “use HRT at the lowest dose for the shortest time” was never evidence-based, and this is now evidence against it. The other mantra that HRT must be stopped on safety grounds after 5 years duration should be blown out of the water!”

Surely now both women and healthcare professionals can again take and prescribe HRT when required for control of menopausal symptoms, or for treatment or prevention of osteoporosis without undue concern about risk and with reassurance about heart benefit when started early.


Links to BMJ articles:

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